GENERAL PROVISIONS

§21.251. Definitions.

The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise:

Boards—The State Board of Nursing and the State Board of Medicine.

Certified Registered Nurse Practitioner (C.R.N.P.)—A registered nurse licensed in this Commonwealthwho is certified by the Boards in a particular clinical specialty area and who, while functioning in theexpanded role as a professional nurse, performs acts of medical diagnosis or prescription of medical  therapeutic or corrective measures in collaboration with and under the direction of a physician licensed topractice medicine in this Commonwealth. Nothing in this subchapter is to be deemed to limit or prohibit anurse from engaging in those activities which normally constitute the practice of nursing as defined in section 2 of The Professional Nursing Law (63 P. S. §  212).

Direction—The incorporation of physician supervision to the certified registered nurse practitioner’sperformance of medical acts in the following ways:

(i)   Immediate availability of a licensed physician through direct communications or by radio, telephone or telecommunications.
(ii)   A predetermined plan for emergency services which has been jointly developed by the supervisingphysician and the certified registered nurse practitioner.
(iii)   A physician available on a regularly scheduled basis for

(A)   Referrals.
(B)   Review of the standards of medical practice incorporating consultation and chart review.
(C)   Establishing and updating standing orders, drug and other medical protocols within the practicesetting.
(D)   Periodic updating in medical diagnosis and therapeutics.
(E)   Cosigning records when necessary to document accountability by both parties.

Source

The provisions of this §  21.251 adopted July 22, 1977, effective July 23, 1977, 7 Pa.B. 2063.

Notes of Decisions

Chart Review

Physicians may render an opinion based on a review of records. Therefore, the physician was justified informulating a medical opinion based on the information provided by the certified registered nurse practitioner and the suspension of the petitioner’s license based on incompetence under 67 Pa. Code

§ 83.5 was justified. Satler v. Department of Transportation, 670 A.2d 1205 (Pa. Cmwlth. 1996).

§21.252. Purpose.

The Boards have established rules and regulations to govern acts of medical diagnosis or prescription ofmedical therapeutic or corrective measures as authorized by The Professional Nursing Law (63 P. S.§ §  211—225) and the Medical Practice Act of 1974 (63 P. S. § §  421.1—421.18) (Reserved).

Source

The provisions of this §  21.252 adopted July 22, 1977, effective July 23, 1977, 7 Pa.B. 2063.

§21.253. Fees.

The following fees are charged by the Board:

Certification …$100
Biennial renewal of certification …$50
Verification of certification …$15

Authority

The provisions of this §  21.253 issued under section 11.2(a) and (d) of The Professional Nursing Law (63 P. S. §  221.2(a) and (d)); amended under section 11.2 of The Professional Nursing Law (63 P. S.§  221.2); and section 17.5 of the Practical Nurse Law (63 P. S. §  667.5).

Source

The provisions of this §  21.253 adopted December 25, 1987, effective December 26, 1987, 17 Pa.B.5329; amended June 12, 1992, effective immediately and applies to biennial renewals commencing May 1,1992; amended June 16, 2000, effective June 17, 2000, 30 Pa.B. 3040; amended November 17, 2000,effective November 18, 2000, 30 Pa.B. 5952. Immediately preceding text appears at serial page (267604).

Cross References

This section cited in 49 Pa. Code §  21.605 (relating to biennial renewal).

LEGAL RECOGNITION

§21.261. Designation of C.R.N.P.; authority to use C.R.N.P.

(a)  A registered nurse who has satisfactorily met the requirements set forth in this subchapter and inadditional rules and regulations that may be jointly promulgated by the Boards shall be designated on hislicense ‘‘Certified Registered Nurse Practitioner (C.R.N.P.),’’ in the area for which qualified.
(b)  A nurse may not practice or offer to practice as a Certified Registered Nurse Practitioner in this Commonwealth or use the abbreviation C.R.N.P. unless authorized to do so by the State Board of Nursing.

Source

The provisions of this §  21.261 adopted July 22, 1977, effective July 23, 1977, 7 Pa.B. 2063.

REQUIREMENTS FOR APPROVAL

§21.271. Currently licensed; course of study and experience; continuing education.

(a)  The applicant for whom approval is requested shall be currently licensed as a registered nurse by theState Board of Nursing.
(b)  The applicant shall have successfully completed a course of study consisting of at least 1 academic yearin a program administered by nursing in an institution of higher education as approved by the Boards. 
(c)  Nurses currently practicing in the role covered by this subchapter prior to the promulgation of thissubchapter who have not completed an approved course of study, may individually petition the Boards forcertification within 2 years following the final filing of this subchapter.
(d)  Evidence of continuing competency in the area of medical diagnosis and therapeutics at the time of  renewal of the applicant’s certification renewal.

Source

The provisions of this §  21.271 adopted July 22, 1977, effective July 23, 1977, 7 Pa.B. 2063.

The applicant shall submit an application form provided by the State Board of Nursing to the Board for itsreview and approval. The application shall include the following:

(1)  An official document from the program.
(2)  Additional information as identified on the application.

Source

The provisions of this §  21.281 adopted July 22, 1977, effective July 23, 1977, 7 Pa.B. 2063.

§21.282. Approval by the State Board of Nursing.

Applicants approved by the State Board of Nursing may use the designation C.R.N.P., and the designationand area of specialty will be indicated on the current license of the nurse.

Source

The provisions of this §  21.282 adopted July 22, 1977, effective July 23, 1977, 7 Pa.B. 2063.

CRNP PRACTICE

§21.283. Prescribing and dispensing drugs.

A CRNP may prescribe and dispense drugs if the following requirements are met:

(1)  The CRNP has completed a CRNP program which is approved by the Boards or, if completed inanother state, is equivalent to programs approved by the Boards.
(2)  The CRNP has successfully completed at least 45 hours of course work specific to advancedpharmacology in accordance with the following:

(i)   The course work in advanced pharmacology may be either part of the CRNP education program or,if completed outside of the CRNP education program, an additional course or courses taken from aneducational program or programs approved by the Boards.
(ii)   The course work shall be at an advanced level above a pharmacology course required by aprofessional nursing (RN) education program.

(3)  A CRNP who has prescriptive authority shall complete at least 16 hours of State Board of Nursingapproved continuing education in pharmacology in the 2 years prior to the biennial renewal date of theCRNP certification. The CRNP shall show proof that the CRNP completed the continuing education whensubmitting a biennial renewal.
(4)  In prescribing and dispensing drugs, a CRNP shall comply with standards of the State Board ofMedicine in § §  16.92—16.94 (relating to prescribing, administering and dispensing controlled substances;packaging; and labeling of dispensed drugs) and the Department of Health in 28 Pa. Code§ §  25.51—25.58, 25.61—25.81 and 25.91—25.95.

Authority

The provisions of this §  21.283 issued under section 15(b) of the Medical Practice Act of 1985 (63 P. S.§  422.15(b)).

Source

The provisions of this §  21.283 adopted November 17, 2000, effective November 18, 2000, 30 Pa.B.5943.

§21.284. Prescribing and dispensing parameters.

(a)  The Board adopts the American Hospital Formulary Service Pharmacologic-Therapeutic Classificationto identify drugs which the CRNP may prescribe and dispense subject to the parameters identified in thissection.
(b)  A CRNP may prescribe and dispense a drug relevant to the area of practice of the CRNP from thefollowing categories if that authorization is documented in the collaborative agreement (unless the drug islimited or excluded under this or another subsection):

(1)  Antihistamines.
(2)  Anti-infective agents.
(3)  Antineoplastic agents, unclassified therapeutic agents, devices and pharmaceutical aids if originallyprescribed by the collaborating physician and approved by the collaborating physician for ongoing therapy.
(4)  Autonomic drugs.
(5)  Blood formation, coagulation and anticoagulation drugs, and thrombolytic and antithrombolytic agent
(6)  Cardiovascular drugs.
(7)  Central nervous system agents, except that the following drugs are excluded from this category:

(i)   General anesthetics.
(ii)   Monoamine oxidase inhibitors.

(8)  Contraceptives including foams and devices.
(9)  Diagnostic agents.
(10)  Disinfectants for agents used on objects other than skin.
(11)  Electrolytic, caloric and water balance.
(12)  Enzymes.
(13)  Antitussive, expectorants and mucolytic agents.
(14)  Gastrointestinal drugs.
(15)  Local anesthetics.
(16)  Eye, ear, nose and throat preparations.
(17)  Serums, toxoids and vaccines.
(18)  Skin and mucous membrane agents.
(19)  Smooth muscle relaxants.
(20)  Vitamins.
(21)  Hormones and synthetic substitutes.

(c)  A CRNP may not prescribe or dispense a drug from the following categories:

(1)  Gold compounds.
(2)  Heavy metal antagonists.
(3)  Radioactive agents.
(4) Oxytocics.

(d)  If a collaborating physician determines that the CRNP is prescribing or dispensing a druginappropriately, the collaborating physician shall immediately take corrective action on behalf of the patientand notify the patient of the reason for the action and advise the CRNP as soon as possible. This action shallbe noted by the CRNP or the collaborating physician, or both, in the patient’s medical record.
(e)  Restrictions on CRNP prescribing and dispensing practices are as follows:

(1)  A CRNP may write a prescription for a Schedule II controlled substance for up to a 72 hour dose. The CRNP shall notify the collaborating physician as soon as possible but in no event longer than 24 hours.
(2)  A CRNP may prescribe a Schedule III or IV controlled substance for up to 30 days. Theprescription is not subject to refills unless the collaborating physician authorizes refills for that prescription.

(f)  A CRNP may not:

(1)  Prescribe or dispense a Schedule I controlled substance as defined in section 4 of the ControlledSubstance, Drug, Device and Cosmetic Act (35 P. S. §  780-14).
(2)  Prescribe or dispense a drug for a use not approved by the United States Food and DrugAdministration without approval of the collaborating physician.

(3)  Delegate prescriptive authority specifically assigned to the CRNP by the collaborating physician toanother health care provider.

(g)A prescription blank shall bear the certification number of the CRNP, name of the CRNP in printedformat at the top of the blank and a space for the entry of the DEA registration number, if appropriate. Thecollaborating physician shall also be identified as required in §  16.91 (relating to identifying information on prescriptions and orders for equipment and service).
(h)  The CRNP shall document in the patient’s medical record the name, amount and dose of the drugprescribed, the number of refills, the date of the prescription and the CRNP’s name.

Authority

The provisions of this §  21.284 issued under section 15(b) of the Medical Practice Act of 1985 (63 P. S.§  422.15(b)).

Source

The provisions of this §  21.284 adopted November 17, 2000, effective November 18, 2000, 30 Pa.B.5943.

Cross References

This section cited in 49 Pa. Code §  21.285 (relating to collaborative agreement).

§21.284. Prescribing and dispensing parameters.

(a)  The Board adopts the American Hospital Formulary Service Pharmacologic-Therapeutic Classificationto identify drugs which the CRNP may prescribe and dispense subject to the parameters identified in thissection.
(b)  A CRNP may prescribe and dispense a drug relevant to the area of practice of the CRNP from thefollowing categories if that authorization is documented in the collaborative agreement (unless the drug islimited or excluded under this or another subsection):

(1)  Antihistamines.
(2)  Anti-infective agents.
(3)  Antineoplastic agents, unclassified therapeutic agents, devices and pharmaceutical aids if originallyprescribed by the collaborating physician and approved by the collaborating physician for ongoing therapy.
(4)  Autonomic drugs.
(5)  Blood formation, coagulation and anticoagulation drugs, and thrombolytic and antithrombolytic agents.
(6)  Cardiovascular drugs.
(7)  Central nervous system agents, except that the following drugs are excluded from this category:

(i)   General anesthetics.
(ii)   Monoamine oxidase inhibitors.

(8)  Contraceptives including foams and devices.
(9)  Diagnostic agents.
(10)  Disinfectants for agents used on objects other than skin.
(11)  Electrolytic, caloric and water balance.
(12)  Enzymes.
(13)  Antitussive, expectorants and mucolytic agents.
(14)  Gastrointestinal drugs.
(15)  Local anesthetics.
(16)  Eye, ear, nose and throat preparations.
(17)  Serums, toxoids and vaccines.
(18)  Skin and mucous membrane agents.
(19)  Smooth muscle relaxants.
(20)  Vitamins.
(21)  Hormones and synthetic substitutes.

(c)    A CRNP may not prescribe or dispense a drug from the following categories:

(1)  Gold compounds.
(2)  Heavy metal antagonists.
(3)  Radioactive agents.
(4)  Oxytocics.

(d)  If a collaborating physician determines that the CRNP is prescribing or dispensing a druginappropriately, the collaborating physician shall immediately take corrective action on behalf of the patient and notify the patient of the reason for the action and advise the CRNP as soon as possible. This action shall be noted by the CRNP or the collaborating physician, or both, in the patient’s medical record.
(e)  Restrictions on CRNP prescribing and dispensing practices are as follows:

(1)  A CRNP may write a prescription for a Schedule II controlled substance for up to a 72 hour dose.The CRNP shall notify the collaborating physician as soon as possible but in no event longer than 24 hours.
(2)  A CRNP may prescribe a Schedule III or IV controlled substance for up to 30 days. Theprescription is not subject to refills unless the collaborating physician authorizes refills for that prescription.

(f)  A CRNP may not:

(1)  Prescribe or dispense a Schedule I controlled substance as defined in section 4 of the ControlledSubstance, Drug, Device and Cosmetic Act (35 P. S. §  780-14).
(2)  Prescribe or dispense a drug for a use not approved by the United States Food and DrugAdministration without approval of the collaborating physician.
(3)  Delegate prescriptive authority specifically assigned to the CRNP by the collaborating physician toanother health care provider.

(g)  A prescription blank shall bear the certification number of the CRNP, name of the CRNP in printedformat at the top of the blank and a space for the entry of the DEA registration number, if appropriate. Thecollaborating physician shall also be identified as required in §  16.91 (relating to identifying information on prescriptions and orders for equipment and service).
(h)  The CRNP shall document in the patient’s medical record the name, amount and dose of the drugprescribed, the number of refills, the date of the prescription and the CRNP’s name.

Authority

The provisions of this §  21.284 issued under section 15(b) of the Medical Practice Act of 1985 (63 P. S.§  422.15(b)).

Source

The provisions of this §  21.284 adopted November 17, 2000, effective November 18, 2000, 30 Pa.B.5943.

Cross References

This section cited in 49 Pa. Code §  21.285 (relating to collaborative agreement).

§21.286. Identification of the CRNP.

(a)  A patient shall be informed at the time of making an appointment that the patient will be seen by aCRNP.
(b)  A CRNP shall wear a name tag that clearly identifies the CRNP with the title ‘‘certified registered nurse practitioner.’’
(c)  A CRNP who holds a doctorate should take appropriate steps to inform patients that the CRNP is nota doctor of medicine or doctor of osteopathic medicine.

Authority

The provisions of this §  21.286 issued under section 15(b) of the Medical Practice Act of 1985 (63 P. S.§  422.15(b)).

Source

The provisions of this §  21.286 adopted November 17, 2000, effective November 18, 2000, 30 Pa.B.5943.

§21.287. Physician supervision.

(a)  At any time a physician may not supervise more than four CRNPs who prescribe and dispense drugs.This section, however, does not limit the number of collaborative agreements that a physician may have with prescribing CRNPs. By way of example, a physician may supervise four prescribing CRNPs who work in the morning and four other prescribing CRNPs who work in the afternoon as long as the physician has a collaborative agreement with each CRNP.
(b)  A physician may apply for a waiver of the supervision requirements expressed in subsection (a) forgood cause, as determined by the Boards.
(c)  The limit of the general rule of not more than four prescribing CRNPs to one physician does not apply to CRNPs who do not prescribe or dispense drugs. By way of example, a physician may supervise at the same time four CRNPs who prescribe and dispense drugs and one or more CRNPs who do not prescribe and dispense drugs.

Authority

The provisions of this §  21.287 issued under section 15(b) of the Medical Practice Act of 1985 (63 P. S. §  422.15(b)).

Source

The provisions of this §  21.287 adopted November 17, 2000, effective November 18, 2000, 30 Pa.B.5943.